AIRCRAFT ACCIDENT INVESTIGATION · Appendix F - Accident Site Hazards ... prepared by the Air...

AAIBAir Accidents Investigation Branch

AIRCRAFT ACCIDENT

INVESTIGATIONin

THE UK OVERSEAS TERRITORIES

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© Crown copyright 2009 Aircraft Accident Reporting - Telephone number+44 1252 512299

Aircraft Accident Investigation in the UK Overseas Territories

Contents

1. Foreword .......................................................................................................................................12. Introduction ...................................................................................................................................33. The Role of the AAIB .....................................................................................................................64. The AAIB’s obligation to investigate an aircraft accident or serious incident ...............................75. The Role of the Accident Investigation Manager (AIM) .................................................................76. Legal powers of an Inspector of Air Accidents .............................................................................97. Authority to impound an aircraft ....................................................................................................98. The relationship between Judicial Inquiries and AAIB Investigations ...........................................99. Liaison between the AAIB and Police Inquiries ...........................................................................1010. What is a reportable Aircraft Accident .........................................................................................1011. Reporting an Aircraft Accident ................................................................................................1012. What the AAIB need to know ...................................................................................................... 1113. The Overseas Territory and AAIB response ........................................................................... 1114. Firefighting .................................................................................................................................1615. Rescue of personnel from crashed aircraft .................................................................................1616. Survivors .....................................................................................................................................2017. Airfieldoperator’sresponse ........................................................................................................2118. Accident site security and initial AIM/police actions ....................................................................2119. Accident site safety .....................................................................................................................2220. Organisation of the investigation .................................................................................................2321. Preservation of evidence .............................................................................................................2422. The exchange of witness statements .....................................................................................................2723. Communications .........................................................................................................................2724. Pathology - aviation specialists ...................................................................................................2725. Wreckage recovery .....................................................................................................................2826. Aircraft accidents at sea ..............................................................................................................2827. Dealing with the media ................................................................................................................30

Appendix A - Powers of an Inspector .................................................................................................32Appendix B - DefinitionsofanAccidentandSeriousIncident ............................................................34Appendix C - AccidentNotificationFax ...............................................................................................35Appendix D - Passenger Questionnaire .............................................................................................37Appendix E - AircraftAccidentInvestigation-Managingthefirst48hours ........................................38Appendix F - Accident Site Hazards ...................................................................................................43Appendix G - UK Overseas Territories Aircraft Accident Response Training Course .........................45Appendix H - Accident Investigation Manager (AIM) Training Course ................................................47Appendix I - Overseas Territories - Health & Safety and Investigation Support Equipment List .......48Appendix J - Examples of Overseas Territory Aircraft Accident Report Forms (GA and CAT AARF) ...49

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Responses to Air Accidents Investigation Branch (AAIB)Safety Recommendations

Responses recieved to AAIB recommendations made up to 31 December 2007,presented to the Secretary of State for Transport

Progress Report 2008AAIB Interim Report

Accident to Boeing 777-236ER, G-YMMM

at London Heathrow Airport on 17 January 2008

Farnborough House

Berkshire Copse Road

Aldershot, Hants GU11 2HH

Tel: 01252 510300

Telex: 858119 ACCINV G

Fax: 01252 376999

Department for Transport

This bulletin contains facts which have been determined up to the time of issue. This information is published to inform the

aviation industry and the public of the general circumstances of accidents and must necessarily be regarded as tentative and subject

to alteration or correction if additional evidence becomes available.

Extracts can be published without specific permission providing that the source is duly acknowledged.

© Crown copyright 2008

ACCIDENT

Aircraft Type and Registration:

Boeing 777‑236ER, G‑YMMM

No & Type of Engines:

2 Rolls‑Royce RB211 Trent 895‑17 turbofan engines

Year of Manufacture:

2001

Date & Time (UTC):

17 January 2008 at 1242 hrs

Location:

Runway 27L, London Heathrow Airport

Type of Flight:

Commercial Air Transport (Passenger)

Persons on Board:

Crew ‑ 16

Passengers ‑ 136

Injuries:

Crew ‑ 4 (Minor) Passengers ‑ 1 (Serious)

8 (Minor)

Nature of Damage:

Aircraft damaged beyond economic repair

Commander’s Licence:

Airline Transport Pilot’s Licence

Commander’s Age:

43 years

Commander’s Flying Experience:

12,700 hours (of which 8,500 hours were on type)

Last 90 days ‑ 85 hours

Last 28 days ‑ 52 hours

Information Source:

Inspectors Investigation

All times in this report are UTC


AIRCRAFT

ACCIDENT

INVESTIGATIONin

THE UK OVERSEAS

TERRITORIES

AAIB Bulletin S2/2008

SPECIALFarnborough House

Berkshire Copse Road

Aldershot, Hants GU11 2HH

Tel: 01252 510300

Telex: 858119 ACCINV G

Fax: 01252 376999

Department for Transport

This bulletin contains facts which have been determined up to the time of issue. This information is published to inform

the aviation industry and the public of the general circumstances of accidents and must necessarily be regarded as

tentative and subject to alteration or correction if additional evidence becomes available.

Extracts can be published without specific permission providing that the source is duly acknowledged.


ACCIDENT

Aircraft Type and Registration:

Cessna Citation 500, VP-BGE

No & Type of Engines:

2 x Pratt & Whitney (Canada) JT15D-1A turbofans

Year of Manufacture:

1975

Date & Time (UTC):

30 March 2008 at 1338 hrs

Location:

Romsey Close, Farnborough, Kent

Persons on Board:

Crew - 2

Passengers - 3

Injuries:

Crew - 2 (Fatal)

Passengers - 3 (Fatal)

Nature of Damage:

Aircraft destroyed

Commander’s Licence:

Airline Transport Pilot’s Licence

Commander’s Age:

57 years

Commander’s Flying Experience:

8,280 hours (of which 32 were on type)

Last 90 days - 44 hours

Last 28 days - 20 hours

Information Source:

AAIB Field Investigation

All times in this report are UTC TO REPORT AN ACCIDENT OR INCIDENTPLEASE CALL OUR 24 HOUR REPORTING LINE

01252 512299

AAIB Bulletin 9/2008

AIR ACCIDENTSINVESTIGATION

BRANCHPUBLICATIONS

ABBREVIATIONS USED IN THIS PUBLICATIONAAIB Air Accidents Investigation BranchAIM Accident Investigation ManagerCVR Cockpit Voice RecorderDfT Department for TransportFDR Flight Data RecorderRAF Royal Air ForceMoD Ministry of DefenceMRT Mountain Rescue TeamSAR Search and RescueUTC Co-ordinated Universal Time (UTC)

Note:WhereGovernor,orGovernor’sOfficeisreferredto,in the context of Gibraltar, this refers to the Government

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1. Foreword

TheEmergencyServicesandthePoliceareusuallythefirsttrainedpersonneltoarriveatanaircraftaccident site. They can render valuable assistance to minimise injury and loss of life and reduce propertylossthroughdamageandfire.Followingtherescueeffort,itisimportanttopreservetheevidence relating to factors that may have contributed to the accident. This booklet has been prepared by the Air Accidents Investigation Branch of the Department for Transport to assist these personnel in better understanding the essential processes that need to be followed in the aftermath of an aircraft accident. Additionally it details some of the hazards that may exist at aircraft accident sites and the accident investigation process that will follow.

The normal sequence of events when a fatal accident occurs is as follows:

The accident occurs ●

The Emergency Services respond ●

TheaccidentisreportedtotheGovernor’sOfficeandtheAAIB(byAirTrafficControl,thePolice, ●the Pilot, the Operator or an eye witness)

Governor’sOfficeappointsanAIMtomanagetheinitialinvestigation ●

An AAIB ‘Field’ team is dispatched from the UK ●

Priority action is taken by the Police to secure accident site as the Emergency Services complete ●their task

TheAIMandteamarriveand,afterasitebriefingfromthePoliceincidentcommander,they ●commencepreservationofthesitewreckage,retrieveanyflightrecordersandcollectdataincluding any witness statements taken by the police

TheAAIBteamarriveand,afterabriefingfromtheAIM,willleadtheinvestigationanddevelopa ●reportforpublicationinconsultationwiththeGovernor’sOffice

TO REPORT AN AIRCRAFT ACCIDENT or SERIOUS INCIDENT

Telephone the Air Accidents Investigation Branch (AAIB) on +44 1252 512299 (24 Hours)

Note: During normal working hours the above telephone number will be answered directly by personnel from the AAIB. Outside normal working hours calls will be diverted automatically to the Department for Transport DutyOfficerwhowill,afterrecordingsomeinitialdetails,contactAAIBdutypersonnel.

GENERAL ENQUIRIES

Air Accidents Investigation Branch, Farnborough House, Berkshire Copse Road, Aldershot, Hampshire, GU11 2HH. Tel: +44 1252-510300, Fax: +44 1252-376999, E-mail: [email protected] (monitored 0830-1700 hrs Mon to Fri)Website: www.aaib.gov.ukDepartmentforTransportPressOffice(officehours)+442079443118(othertimes)+442079444292


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Aircraft Accident Reporting - Telephone number+44 1252 512299



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2. Introduction

The Convention on International Civil Aviation (“the Convention”) came into force in April 1947. Article 26 to the Convention deals with the subject of investigation of accidents and provides that:

‘in the event of an accident to an aircraft of a contracting State occurring in the territory of another contracting State, and involving death or serious injury, or indicating serious technical defect in the aircraft or air navigation facilities, the State in which the accident occurs will institute an inquiry into the circumstances of the accident, in accordance, so far as its laws permit, with the procedure which may be recommended by the International Civil Aviation Organisation.’

The article only requires an accident investigation to be undertaken in a State of occurrence when the accident involves an aircraft registered in another State. Article 37 to the Convention deals with the adoption of international standards and procedures. The article provides for the adoption by Contracting States of uniform regulations and standards. To that end the International Civil Aviation Organisation (ICAO) shall adopt and amend from time to time, as may be necessary, international standards and procedures dealing with (inter alia) aircraft in distress and investigation of accidents.

In accordance with Article 37, ICAO has adopted and amended from time to time Annex 13 - entitled Aircraft Accident and Incident Investigation - that contains the standards and recommended practices to be adopted by contracting States in relation to this subject. In particular, the Council of ICAO has recommended that whilst the standards

adoptedaredesignedspecificallytoapplyto the requirements of Article 26 they should also be applied in the event of an inquiry into any aircraft accident. In practice many States conduct investigations into aircraft accidents within their respective territories regardless of whether or not the aircraft involved is/are registered in another State.

One of the key elements of Annex 13 is that the accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct. Having said that, ICAO notes that nothing in the standard is intended to preclude the State conducting the investigation from calling upon the best technical expertise from any source. ICAO further recommends that any judicial or administrative proceedings to apportion blame or liability should be separate from any investigation conducted under the provisions of Annex 13. The Annex makes clear that the sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents and that it is not the purpose of such an investigation to apportion blame or liability.

Legislative implementation of the Convention in the UK

The UK implemented and gave effect to the Convention by the enactment of the Civil Aviation Act 1949. Section 8 of the Act provides for His Majesty, by Order in Council, to make provision for carrying out the Convention and any Annex thereto relating to international standards and recommended practices. That sectiondoesnotcontainanyspecificreferenceto the investigation of accidents; however Section 10 makes provision for investigation of accidents and empowers the Minister to make regulations for the investigation of any accident arising out of or in the course of air navigation and either occurring in or over the UK or occurring elsewhere to British aircraft registered in the UK.

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The relevant provisions of the Act (including in particular Sections 8 and 10) were extended to and applied in the Overseas Territories by the Civil Aviation Act 1949 (Overseas Territories) Order 1969. That Order still provides the statutory framework for civil aviation regulation in the Overseas Territories. The Order provides fortheGovernor’sOfficetomakeregulationsfor the investigation of accidents occurring in or over the Colony or elsewhere to British aircraft registered in the Colony.

In the UK, the Civil Aviation Act 1949 has been repealed by subsequent legislation, in particular the Civil Aviation Act 1982. Section 60 of the 1982 Act replicates, more or less, Section 8 of the 1949 Act. The 1982 Actcontainsspecificprovisionsrelatingtotheinvestigation of accidents and provides that:

‘the Secretary of State may by regulations under this section make such provision as appears to him to be requisite or expedient for the investigation of any accident arising out of or in the course of air navigation and either occurring in or over the United Kingdom or occurring elsewhere to aircraft registered in the United Kingdom;’

and for carrying out any Annex to the Chicago Convention (relating to the investigation of accidents involving aircraft) as it has effect from time to time with any amendment made in accordance with the Convention. The section goes on to make further provision for the implementation of the requirements. It also contains penalties for non-compliance with any regulations.

The 1982 Act has not been extended generally to the Overseas Territories. However, Section 75 has been extended by the Civil Aviation Act 1982 (Overseas Territories) Order 2001. Paragraph 2 to Schedule 1 to the Order provides for the Governor’s Officebyregulationtomakeprovisionfor

the investigation of accidents occurring in or over a Territory or elsewhere to an aircraft registered in a Territory. Section 10 of the 1969 Order was at the same time repealed.

Pursuant to Section 75, the Governor’s OfficeinalloftheTerritories(saveforthosehaving no civil aviation activity) have made regulations as follows:

Anguilla 31 March 2005Bermuda 1 June 2001BVI 4 October 2004Cayman Islands 2007Falkland Islands 12 May 1997Montserrat 13 December 2007TCI 10 November 2003

The Government of Gibraltar enabled similar regualtions in January 2009.

All of the regulations contain provisions relating to the appointment of Inspectors of Air Accidents. Although the actual wording of the regulations varies slightly from territory to territory, in general terms the regulations (Regulation 7(1) or 8(1) as the case may be) provide as follows:

“For the purpose of carrying out investigations into accidents and incidents to which these Regulations apply, the Governor shall appoint persons as Inspectors of Air Accidents.”

The regulations further provide (7(6) or 8(6) as the case may be) that the Inspector may seek such advice or assistance as he may deem necessary and, without prejudice thereto, the Governor’sOfficemayappointpersonstoassist any Inspector in a particular investigation. Regulation 7(7) (or 8(7) as the case may be) provides that in any case where the Governor’s OfficeappointsmorethanoneInspectortocarry out an investigation, he shall nominate one of them to be in overall charge of the investigation. This person is known as the Investigator-in-Charge (IiC).

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Implementation of requirements

Memoranda of Agreement or Arrangements have been signed between the Governor’s OfficesoftheTerritoriesandtheAAIB,under which the AAIB has agreed to assist theGovernor’sOfficesintheeventoftheneed for an investigation into an accident or serious incident.

To meet the UK’s obligations under the Convention in full and to formalise the arrangements it was considered necessary thateachGovernor’sOfficeshouldformallyappointtheholderoftheofficeofChiefInspector of the AAIB as the Chief Inspector of Air Accidents (CIAA) for each of the Territories to meet the requirements of Regulation 7(1)/8(1).

This procedure has the effect of putting in place a formal link between the Governor’s OfficeofaTerritoryandtheindependentinvestigation authority in accordance not only with the regulations in force in each Territory but also with the provisions of Annex 13 to the Convention. The arrangement will obviate the need to have an appointment made on each occasion upon when it becomes necessary and is consistent with the terms of the relevant article of the Territories’ Regulations.

The Letter of Appointment acknowledges the intention of the Chief Inspector to appoint one or more inspectors from within the AAIB to undertakeaninvestigationinanyspecificcaseandconfirmtheGovernor’sOfficeagreementto such appointment. This process formally endorses the appointment of an individual inspectorforeachspecificaccident/seriousincident and is consistent with the exercise oftheGovernor’sOffice’spowersunderRegulation 7(6) or 8(6), as the case may be - and in the case of Bermuda Regulation 7(12). Even though the agreement of the Governor’s Officeisobtainedinadvanceofanyspecificappointment, such an arrangement is not inconsistent with the exercise of the Governor’s

Office’spowersundertheRegulationnordoesit appear to constitute an unlawful delegation by theGovernor’sOfficetotheCIAA.Itisalwayspossible to have an understanding that any appointment made by the CIAA of an individual inspector is subject to endorsement by the Governor’sOfficeinanyspecificcase.TheCIAA remains as the Investigator in Charge and the individual inspector would report to him/her in that capacity.

In practice the majority of accidents that occur in the Territories are non-fatal and involve small aircraft. Such accidents do not normallyjustifyafullfieldinvestigationbytheAAIB. In such cases there is a need for the appointment, within each Territory, of one or more local personnel trained to undertake the role of Accident Investigation Manager. Whilst the person appointed has the same powers of an Inspector under regulation 7(7) or 8(7), any activity undertaken by that person is so undertaken in accordance with directions given by the appointed Inspector from the AAIB and will comprise tasks such as organising the removal of aircraft wreckage to a safe location; taking statements; taking photographs and otherwise collecting information in order to enable the AAIB to produce a report to the Governor’sOffice.

In the event of a more serious accident, ie one involving fatalities and/or large commercial air transport aircraft, there is still be a need for involvement in the investigation of a locally-based Accident Investigation Manager to undertake certain tasks on behalf of the AAIB and to act in a coordination role.

Summary

In the context of the above arrangements it is possible to summarise the roles of various parties in the following way:

Governor’s Office –TheGovernor’sOfficewill always retain the legal responsibility for the appointment of an Inspector of Air

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Accidents,eithergenerallyorinaspecificcase in accordance with the regulations in force in his Territory. The Governor’s Officecandischargethatresponsibilitybythe Letter of Appointment in favour of the Chief Inspector of Air Accidents of the AAIB. TheGovernor’sOfficeretainstherightto appoint one or more persons to assist in an investigation, including an Accident Investigation Manager. The Governor’s Officeretainstherightandresponsibilityfor receiving the accident report and for publishing it in appropriate cases.

AAIB – AAIB has overall responsibility for the conduct of accident investigations in the Territories. The Chief Inspector, with the agreementoftheGovernor’sOffice,hastheright to appoint one or more Inspectors from hisstafftoundertakeaspecificinvestigation.The AAIB has the responsibility to compile areportandtogiveallrelevantnotificationsto ICAO and other States as required under Annex 13.

Accident Investigation Manager (AIM) – The AIM will be appointed by the Governor’s OfficeandbeavailabletoassistAAIBinthe conduct of an investigation. The person appointed will have the same powers as an Inspector within the scope of his/her appointment.

3. The Role of the AAIB

The Air Accidents Investigation Branch (AAIB) is an operationally independent organisation embedded within the Department for Transport and completely separate from the Civil Aviation Authority. It is responsible for the investigation of civil aircraft accidents and serious incidents within the United Kingdom. The AAIB is also frequently called upon to assist with military and overseas investigations. The Chief Inspector of Air Accidents is responsible directly to the Secretary of State for Transport.

Under current legislation and in conformity with International Convention the AAIB is the body responsible in the UK for the investigation of aircraft accidents and serious incidents in accordance with:

Annex 13 to the International Civil ●Aviation Organisation Convention (ICAO)

The European Union Council Directive ●94/56/EC

Statutory Instrument No. 2798 of ●1996; The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996

The AAIB’s purpose is:

To improve aviation safety by determining the causes of air

accidents and serious incidents and making safety

recommendations intended to prevent recurrence

It is not the purpose of AAIB investigations to apportion blame or liability.

In carrying out its purpose the AAIB strives to:

Respond quickly to air accidents and ●serious incidents and lead and manage the accident investigation team and ensure their safety at the accident location

Develop and maintain effective ●working relationships with emergency service providers at accident sites and throughout the remainder of an investigation

Conduct thorough, independent, ●impartial and timely investigations into air accidents and serious incidents.

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Treat the survivors and relatives of ●victims of air accidents sympathetically and help them to understand ‘what happened’ and what is being done to prevent similar accidents in the future

Produce clearly written, thorough and ●concise reports with well-founded analysis and conclusions that explain the circumstances and causes of accidents and serious incidents, without attributing blame

Improve aviation safety in general by ●education and promulgating the lessons learnt from accident investigations

Ensure that the UK complies with its ●national and international statutory obligations for the investigation of air accidents and incidents

4. The AAIB’s obligation to investigate an aircraft accident or serious incident

Every reported aircraft accident or serious incident, to which the Regulations apply shall be the subject of an AAIB investigation.

Additionally the Chief Inspector of Air Accidents may take measures to investigate any incident that is not a serious incident where he or she considers that such an investigation may be expected to draw significantairsafetylessons.

The extent of investigations and the procedures to be followed in carrying them out shall be determined by the Chief Inspector of Air Accidents.

5. The Role of the Accident Investigation Manager (AIM)

TheGovernor’sOfficeshouldappointalocal Accident Investigation Manager (AIM) who, working with other suitably trained

key personnel, the police and emergency services, will manage the initial accident investigation until the AAIB team arrives on site.

The person appointed will have the same powers as an Inspector of Air Accidents within the scope of his/her appointment. The AIM may be the Director of Civil Aviation (DCA), the Airport Manager, the Police CommissioneroranyotherSeniorOfficialwith the necessary knowledge and training to manage the initial actions required in an aircraft accident investigation. It is recommendedthattheGovernor’sOfficeappoints at least two AIM’s to ensure full time cover is maintained. The responsibilities of the AIM include:

Capability to deploy a suitably trained ●team to the accident site

Preservation of accident site and ●evidence until AAIB team arrives

Hosting of international Accredited ●Representatives and coordination of their activities

Interface with the Police and the media ●

Communication with AAIB HQ and ●briefingtheAAIBteamontheirarrival

Continued participation in the ●investigation as advisor to the AAIB

Maintaining the Accident Investigation ●and Personal Protective Equipment held in each Territory (Appendix I)

Ensuring familiarity with the 48 hour ●checklist (Appendix E)

Participation in UK Overseas Territories ●Aircraft Accident Response Training Course (Appendix G)

Participation in AIM Training course ●(Appendix H)

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6. Legal powers of an Inspector of Air Accidents

The Regulations grant legal powers to Inspectors of Air Accidents. An AIM will have the same powers as an Inspector within the scope of their appointment. A full list of these powers is enclosed at Appendix A.

The powers most relevant to an Inspector of Air Accidents working alongside the Police and Emergency Services at the site of an aircraft accident are as follows:

To have free access to the site of the ●accident or incident as well as to the aircraft, its contents or its wreckage

To ensure an immediate listing of ●evidence and controlled removal of debris, or components for examination or analysis purposes

To take such measures for the ●preservation of evidence as he considers appropriate

To have immediate access to and use of ●thecontentsoftheflightrecordersandany other recordings

To take statements from all such persons ●ashethinksfitandtorequireanysuchperson to make and sign a declaration of the truth of the statement made by him

7. Authority to impound an aircraft

Some AAIB investigations involve the detailed examination or assessment of an aircraft that has not been damaged. In that case, an AAIB Inspector may impound the aircraft using his or her regulatory powers.

Apart from AAIB Personnel, authorised persons include any police constable or any Customs and Excise officer.

8. The relationship between Judicial Inquiries and AAIB Investigations

The Regulations make it clear that AAIB Inspectors must perform their statutory duties in co-operation with the authorities responsible for the judicial inquiry. The police may conduct an inquiry to determine if a crime has been committed.

The AAIB will make every effort to establish and maintain good liaison and co-operation with the Police throughout the technical investigation. The aim is to ensure that both the Police and the AAIB investigations can proceed in parallel without either body obstructing the other.

The Lord Chancellor has provided guidance on the relationship between the Police inquiries and the technical investigations conducted by bodies such as the AAIB. This guidance is entitled ‘Disasters and the Law – Deciding the form of Inquiry’. In this Memorandum the Lord Chancellor states that:

‘It would require firm indications of serious criminality to justify a criminal investigation taking precedence over an inquiry held in public (or at least whose results are to be made public) where otherwise the public interest requires that such an inquiry be held. Colleagues will wish to bear in mind that the holding of such an inquiry in advance of criminal proceedings may adversely affect the ultimate prospects of a successful prosecution, but nevertheless, unless the criterion mentioned in the previous sentence is met, this is likely to be justified.’

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9. Liaison between the AAIB and Police Inquiries

AAIB Inspectors often support the judicial inquiry by providing expert witness evidence to the relevant Court. However, the AAIB investigation’s purpose is to establish the circumstances and causes of an accident to ensure that safety action is taken to prevent that accident occurring again. This is an international obligation placed on a State by the Convention on International Civil Aviation (The ‘Chicago Convention’). All the Overseas Territories and Crown Dependency Civil Aviation (Investigation of Air Accidents and Incidents) Regulations state:

‘The sole objective of the investigation of an accident or incident under these Regulations shall be the prevention of accidents and incidents. It shall not be the purpose of this activity to apportion blame or liability.’

Consequently, it is the AAIB’s responsibility, after an accident or incident, to ensure that urgent safety action is disseminated world-wide so that the safety of the travelling public is assured whereas the police role may betoestablishwhetherthereissufficientevidence to justify criminal proceedings.

The different responsibilities between the police inquiry and the AAIB investigation can leadtodifficultiesoveraccesstoanaccidentsite and access to witnesses. There may alsobepotentialconflictsoverthegatheringand retention of evidence, and the need to protect the safety of people within the inner cordon.Theseconflictsshouldandcanbe resolved ‘on-site’ through explanation, cooperation and negotiation.

10. What is a reportable Aircraft Accident

Thefulldefinitionsofanaircraftaccidentandserious incident are contained in the Civil Aviation (Investigation of Air Accidents and Incidents) Regulations and are shown in Appendix B.

Brieflyanaircraft accident is an occurrence, during the period of operation of an aircraft, where the aircraft incurs damage (with certain exceptions) or in which any person suffers death or serious injury.

A serious incidentisdefinedas‘anincidentinvolving circumstances indicating that an accident nearly occurred’; it is unlikely to involve the police or the emergency services, other than those based at airports.

11. Reporting an Aircraft Accident

Thelegalresponsibilityfornotificationofanaircraft accident or serious incident rests firstwiththecommanderoftheaircraftor,if he/she is killed or incapacitated, then the operator. If the accident occurs on or adjacent to an aerodrome, then the aerodrome authority is also required to notify the accident.

All aircraft accidents and incidents occurring in the Overseas Territories should be reported totherelevantGovernor’sOfficeandtheAAIBon the 24 hour reporting number:

+ 44 1252 512299

In practice this will normally be carried out by ATC, the Airport Management, the DCA or Air Safety Services International (ASSI).

The AAIB Duty Coordinator (DC), a Principal Inspector of Air Accidents contactable 24 hours a day, will then decide the appropriate immediate AAIB action which will, when possible, be discussed with the Governor’s

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Office.Theresultingresponsewillthenbecommunicated to the DCA, ASSI and the Governor’sOffice,ifnotpreviouslycontactable.

Accidents to an aircraft registered in an Overseas Territory occurring in a Foreign State (the State of Occurrence) may be reported to the AAIB but more often will normally be reported directly to the Territory as the ‘State of Registration’. In this case the Territory’s DCA should inform the AAIB (using the 24 hour reporting number), as soon as possible, so that the AAIB, in consultation with the Governor’sOffice,canappointanAccreditedRepresentative and liaise directly with the Foreign State’s Investigator-in-Charge.

In either case the DCA and/or selected members of his staff may be appointed as Advisors to the AAIB Investigator-in-Charge or the AAIB Accredited Representative (where the State of Occurrence is not the UK or a UK Territory).

12. What the AAIB need to know

The reporting authority should report the following details where possible:

Aircraft type (eg Boeing 737, Airbus A320) ●

Aircraft registration (letters or numbers) ●

Name of the owner or operator, or ●military operating unit

Names of the pilot / crew and any other ●people on board

Date and time of the accident ●

Aircraft’s last departure point and its ●intended destination

Location of the accident, including ●directions on how to reach the scene and/or any designated rendezvous point (RVP)

Extent of any injuries to the occupant(s) ●or others

NatureoftheaccidentiePhaseofflight ●(eg takeoff, landing etc), and a general description of the occurrence

Extent of damage to the aircraft. ● (A specimen Notification FAX is shown atAppendix C)

Notificationshouldnotbedelayedeventhough all the information may not yet be available.

13. The Overseas Territory and AAIB response

The following paragraphs describe, in a checklist format, the types of aircraft accidents and incidents and:

The Initial actions in the Overseas Territory ●

The AAIB’s response ●

The Overseas Territory’s subsequent ●response

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A. NON-FATAL ACCIDENTS OR INCIDENTS TO GENERAL AVIATION OR COMMERCIAL AIR TRANSPORT AIRCRAFT OCCURRING IN AN OVERSEAS TERRITORY.

The provision of information relating –to the occurrence (date, time, place, pilot’s name and contact details, damage and injuries, circumstances of the occurrence etc)

A description of the investigation –process to be adopted by the AAIB

THE OVERSEAS TERRITORY’S SUBSEQUENT RESPONSE

The DCA, AIM, Airport Manager or ATC Manager should present the pilot with a General Aviation Air Accident Report Form (AARF(OT)) or A Commercial Air Transport AARF(OT) as appropriate. (These should be held locally by the DCA, AIM or the Airport Manager and an example is shown at Appendix J.)

- The pilot will be required to complete the form and return it directly to the AAIB where an appropriate report will be written and published. A copy of the completed report will sent to the Governor’sOfficebeforeitispublishedin one of the AAIB’s monthly Bulletins

- The AIM should respond to any AAIB requests for follow-up enquiries. (Normally the AIM will be called upon to represent the AAIB to collect additional factual evidence if required)

The DCA may conduct a separate investigation on the basis of information contained in the pilot’s Mandatory Occurence Report (MOR).

TheGovernor’sOfficeshouldconsiderissuinga brief factual press release concerning the event and the investigation.

INITIAL ACTIONS in the OVERSEAS TERRITORY

The accident or incident should be reported by the aircraft commander or the aircraft operator, ATC,theAirfieldManager,theDCAorthePolice to:

TheGovernor’sOffice –The Police –The AAIB (+44 1252 512299) –The DCA –ASSI –

The Police or DCA should secure and impound the aircraft or wreckage.

Aircraft damage, third party damage, and/or wreckage should be recorded and photographed if possible.

Recordings of ATC/aircraft transmissions should be preserved.

The name and contact details of the pilot and/or operator should be recorded.

The pilot may be required to complete and dispatch an MOR to the DCA.

THE AAIB RESPONSE

The AAIB Duty Coordinator (DC), on call 24 hours a day, will contact the Governor’s Officeorhisstaff,ifpossible,andliaisewiththe person or organisation reporting the accident or incident and the AIM to discuss the immediate actions to be taken including:

The moving of the aircraft or wreckage –if required

The evidence to be protected and –retained

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The accident should be reported by the aircraft commander or, should he be fatally injured the aircraftoperator,ATC,theAirfieldManager,the DCA or the Police to:

TheGovernor’sOffice –The Police –The AAIB (+44 1252 512299) –The DCA –ASSI –

The Police should secure and impound the aircraft or wreckage.

TheGovernor’sOfficeshouldappointalocal Accident Investigation Manager (AIM) who, working with other suitably trained key personnel, the police and emergency services, will manage the initial accident investigation until the AAIB team arrives on site.

THE AAIB RESPONSE

The Chief Inspector or AAIB Duty Coordinator, inconsultationwiththeGovernor’sOffice,will appoint an Investigator-in-Charge (IiC) and an AAIB investigation team will deploy to the Overseas Territory concerned as soon as possible.

On arrival at the accident site the AAIB –IiC will take the lead in the Investigation from the AIM and his team

AAIB will be responsible for the –investigation through to the publication of the report

The AAIB will consult with the –Governor’sOfficethroughouttheinvestigation

The IiC may appoint the DCA or a –member of ASSI as advisors when appropriate

The AAIB will provide the Governor’s –Officewithacopyofthedraftfinalreportand when appropriate the DCA / ASSI and interested parties

TheAAIBwillpublishthefinalreport –onbehalfoftheGovernor’sOfficeandwillprovidehimwithacopyofthefinalreport prior to publication


The locally appointed Accident Investigation Manager should establish and maintain communications with the AAIB Duty Co-ordinator (acting on behalf of the IiC while the AAIB team are in transit) throughout the initial phase of the investigation so that appropriate advice can be given if required.

The AIM and local team should continue to participate in the investigation as advisors to the AAIB IiC.

The AIM should coordinate the activities of the Accredited Representatives and their advisors arriving from Foreign States who, under the provisions of ICAO Annex 13, have a right to participate in the investigation and may arrive at the accident site before the AAIB team. However, their experience and expertise should not be ignored and should be used by the AIM when appropriate and in consultation with the AAIB Duty Co-ordinator.

TheGovernor’sOfficeshouldconsiderissuinga brief preliminary factual press release pending the arrival of the AAIB team.

B. FATAL ACCIDENTS OR INCIDENTS TO GENERAL AVIATION OR COMMERCIAL AIR TRANSPORT AIRCRAFT OCCURRING IN AN OVERSEAS TERRITORY.

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The investigation of accidents to aircraft registered in a UK Overseas Territory will normally be conducted by an IiC appointed by the State of Occurrence. The State of Occurrence should, in complying with the recommended practices detailed in ICAO Annex 13, notify the State of Registry, the State of the Operator, the State of Design, the State of Manufacture, ICAO and any other State with a special interest. These States have a right, by International Convention, to appoint an Accredited Representative (Acc Rep) who can be assisted by appointed advisors.


TheDCAshouldInformtheGovernor’sOfficeand the AAIB (using the 24 hour reporting number +44 1252 512299) as soon as possible as it will not normally be known by the State of Occurrence that the AAIB will be acting as the Territory’s representative for accident investigation purposes.

The DCA (or ASSI acting as the DCA) should identify appropriate personnel to act as advisors to the AAIB Acc Rep.

The DCA (or ASSI acting as the DCA) should impound all the relevant records relating to the aircraftanditscertification,maintenance,crewlicensing etc.

THE AAIB RESPONSE

The AAIB will provide the Acc Rep, in consultationwiththeGovernor’sOffice,foraccidents involving aircraft registered in a UK Overseas Territory occurring in a Foreign State.

The AAIB will liaise with the appropriate DCA, ASSI and Operator regarding the appointment of relevant advisors.

The AAIB Acc Rep (and his advisors) will normally travel to the State of Occurrence for major accident investigations, however, their travel may not be required for serious incidents.

The AAIB will provide advisors with a signed letter of authority if, in the unlikely event, they are required to travel to the State of Occurrence, and participate in an investigation, in the absence of the AAIBAcc Rep.

The AAIB Acc Rep will remain the focus for all communications between the Overseas Territory and the IiC and will coordinate any representations made during the consultationphaseofthefinalreport’sproduction.


Advisors should provide feedback to the AAIB Acc Rep on their activities.

TheGovernor’sOfficemaywishtoissueapress release but this will only be relevant if the aircraft normally uses the Territory as its main base of operations.

C. ACCIDENTS OR INCIDENTS TO A GENERAL AVIATION OR COMMERCIAL AIR TRANSPORT AIRCRAFT REGISTERED IN AN OVERSEAS TERRITORY AND OCCURRING IN A FOREIGN STATE.


15

Aircraft Accidents - GuidanceforthePolice,EmergencyServicesandAirfieldOperators AAIB

Air Accidents Investigation Branch


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14. Fire fighting

To ensure the maximum preservation of evidence,itisvitalthatanyfireisextinguishedas soon as possible. Where possible post-impactfiresorsmoulderingdebrisshouldbe extinguished/cooled to limit the loss of evidence and to reduce the occupational health risks at site.

As soon as all has been done to save life and minimise injury, the wreckage and accident site should be disturbed as little as possible. Firefightersarerequestedtousefirefightingfoam only where it is necessary as its use can on occasions inadvertently increase risks. The foam blanket may hide safety hazards or increase the risks from exposure to hazards, as well as covering human remains and hiding or damaging vital evidence. Therefore, it is requested that the laying of a precautionary foam carpet should only be carried out when a realandsignificantfirehazardexists.

15. Rescue of personnel from crashed aircraft

Note: Parts of this section are for guidance only. Trained emergency services personnel should follow their own established procedures.

Rescue and the care of survivors is the firstpriorityatanaircraftaccidentsite.Ifsurvivors appear to be in the aircraft and rescue appears possible, consider the following:

Use care in approaching the main ●wreckage by vehicle, particularly if the approach is along the crash path, as survivors may have been ejected from disrupted fuselages. It is possible that firstrespondersonthescenemayfindno one else present in the wreckage or at the site. The aircraft occupants may have parachuted to safety, may have survived and left the scene to seek assistance, or may have been consumed in the wreckage

Approach the site from upwind (with the ●wind at your back) to avoid inhalation of gases, vapours and burning materials which are hazardous and toxic

A wide variety of hazards may be ●present at air accident sites, and can pose variable levels of risk to response personnel. Fuel and other flammablefluids,damagedandunstable structures, stored energy systems, blood-borne pathogens and products of combustion, are some of the hazards that need to be considered. Suitable control measures should be applied to ensure that risks are adequately controlled. Emergency response organisations will no doubt incorporate hazards details into their risk assessment/management process


Aircraft Accident Investigation in the UK Overseas Territories AAIBAir Accidents Investigation Branch

17


Look around the crash path, and ●maintain a clear observation of the accident site and associated hazards

Renderfirstaidandcaretosurvivors ●where possible, until relieved by medical personnel

Attempt to account for all occupants. ●The airline, operator, or ATC may be able to provide details of the number of persons onboard. Consider that where theaircrafthasdisintegratedinflight,thewreckage, survivors and casualties may be scattered over a large area

Summon medical assistance if required ●and, in due course, verify that this assistance has been sought. Ensure that casualties still present at the accident site are provided with adequate protection against potential site hazards

If there are risks of a spreading ●post-accidentfireorpossibleexplosionfrom fuels or armaments, move survivors a safe distance from the scene. If survivors contaminated with hazardous substances require immediate evacuation to medical facilities, they should be decontaminated if possible prior to being removed. For example, military aircrew life vests contain explosives and hazardous materials and civillifejacketsthatarenotinflatedmaycontain pressurised gas bottles. These should be removed and stowed in a safe location at the accident site

Access

In general, information related to access, rescue and the operation of doors and canopies, will often be printed in red or black and yellow text on the aircraft.

Typical external door handle markings

On civil aircraft, the position of emergency equipment on aircraft, which is accessible from outside the aircraft, is generally indicated by a silhouette with an associated written description. Markings indicating where a first-aidkitiscarriedwilloftenbefoundadjacent to an access panel or door from which the kit is accessible.

Emergency cutting area on aircraft fuselage

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For the purpose of rescue on military aircraft, the location of access doors, hatches, break-in points and cut-out panels are generally indicated on the external surfaces by a yellow arrow, bordered in black.

Military aircraft rescue markings

For access doors and hatches a red arrow will indicate the external controls with the operating instructions for the controls nearby. At break-in points and cut-out panels the arrow will indicate an area delineated by a broken line (usually yellow). This area may be cut out to gain entry to an aircraft interior should access doors be blocked or inoperative. Caution must be exercised when using cutting tools, to avoid igniting spilled fuel, cutting electrical cables, pressure lines, etc.

Systems requiring extra care in their operation or handling due to their containing an explosive device are generally indicated by a red or grey warning triangle.

Ejectorseatsmaybefittedtomilitaryandex-military aircraft. Extreme care must be taken whenever ejection seats are observed to be among the wreckage and must be treated as LIVE.

Under normal circumstances, the words “EJECTION SEAT” contained in a bright red

inverted triangle, located on either side of the cockpit fuselage is an indication that the aircraftisfittedwithejectionseats.

Ejection seat warning on military/ex-military aircraft

The “MAKING SAFE” of ejection seats must be left to trained personnel. The AAIB can arrange for contractors to make ejector seats from civil aircraft safe, whilst military armaments specialists can be called to the scene of accidents involving military aircraft.

TypicalejectorseatfittedtoolderUK ex-military aircraft

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However, if surviving crew urgently need to be removed from an aircraft, utmost care is required to avoid interfering with items such as pull handles, generally colour coded with yellow and black stripes, that operate the ejectionsequenceasthesecaninflictfatalinjuries.

Military aircraft may also have weapons, and armaments pods onboard, whilst civil and military Search and Rescue (SAR) helicopters and aircraft carry a variety of pyrotechnics.

The “MAKING SAFE” and removal of these items must be left to trained personnel.

Ballistic Recovery Systems

One potential hazard rescue workers may encounter on light, general aviation aircraft isanunfired,ballistic recovery system (sometimes called a ballistic parachute). These devices incorporate a parachute, deployed by a rocket which, when activated duringflight,canbringadamagedoroutofcontrol aircraft safely to earth.

If an aircraft, having a ballistic recovery systemfitted,isinvolvedinanaccident,the un-deployed rocket can present a significant risk of injury to rescuers and response personnel.

Rescue personnel responding to an accident involving light general aviation aircraft should look for warning signs or company logos indicatingthefitmentofaballisticrecoverysystem. These are usually positioned on the sides and/or on the upper surface of the fuselage, and/or on the parachute container.

BRS may be produced or installed by a variety of manufacturers, and warning signs and company logos can be variable in appearance. Some examples are shown below.

Ballistic recovery system warning sign

Company logo

Typical BRS Canister system commonly used in ultralight and sport aircraft illustrating the

manufacturers logo

Warning sign found on some aircraft

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WARNING!ROCKET PARACHUTE FOR DEPLOYMENT

INSIDESTAY CLEAR WHEN OCCUPIED

Warning text found on some aircraft

A BRS unit is comprised of four major elements: Activation Handle, activation cable, rocket motor assembly and parachute container. The BRS is initiated by pulling the activation handle, which is located in the cockpit. The rocket motor (about 1½-2 inches diameter and 8-10 inches long) then accelerates to over100mphinthefirsttenthofasecondafter ignition. It is the operation of the rocket whichpresentsasignificantriskofinjurytopersonnel.

A red firing handle,connectedbyflexiblecable to the igniter in the activation housing, is located near the pilot seats.

BRS activation handles

Each type of handle is secured with a safety pin which is intended to be removed prior to flight.

The parachute may be housed in a fabric, metal or composite container and mounted in a variety of locations according to aircraft design. Cables from the parachute, designed to support the aircraft, may be embedded in the aircraft structure or attached to structural components.

Following accidents, emergency response personnel should exercise extreme care when working around these systems, especially if the aircraft is severely damaged. Once components are located, ensure that a safe working zone is established around the rocket/parachute container. In addition, ensure that the activation handle or cable is not disturbed.

It is possible to make the system safe, however, it is recommended that guidance is sought before doing so. Further advice should be sought from manufacturers, or from the AAIB.

One of the current BRS manufacturers is BRS Parachutes Inc. They may be contacted online at:

http://www.brsparachutes.com

or by telephone at:

00 1 763 226 6110

For more detailed information regarding accident site hazards see Appendix F.

16. Survivors

In the immediate aftermath of an accident to a public transport aircraft there may be a number of survivors and injured persons in the area of the wreckage. The emergency services will ensure that the injured receive medical treatment on site with the more serious being removed to hospital. Those with minor injuries may decide to remain close to the site if they have friends or relatives trapped in the wreckage; other passengers may wish to disperse.

Experience has shown that the media will be on site very quickly. Some survivors may wish to talk to the media whereas others may consider this attention to be intrusive and prefer the media to be kept at a distance. Depending upon the circumstances, it may

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be better for the control and protection of the survivors to be carried out by either the airline or the local authority. The emergency services should monitor that this is being done effectively and ensure that a record is kept of names, addresses and (if known) aircraft seat allocation.

An AAIB passenger questionnaire is at Appendix D. Its distribution to, and completion by, surviving passengers can be extremely useful for the AAIB to determine issues surrounding the use of safety equipment, emergency exits and survival.

17. Airfield operator’s response

An accident or serious incident occurring at an airport is likely to cause considerable disruption, particularly if it interferes with runway operation. It is imperative that once firefightingorrescueoperationsarecomplete,the wreckage and any ground marks, are left undisturbed. The AAIB should have been informed by this point and any movement of wreckage must be agreed with the AAIB’s Duty Co-ordinator. The AAIB appreciate that there will be considerable pressure to re-open any closed runways or taxiways and will work with the airport authority to minimise any delay. If the Duty Co-ordinator allows the wreckage to be moved, it will be necessary to record the distribution of the debris and ground marks, preferably by photography and video, before doing so.

Moving a large aircraft, which cannot be supported safely on its landing gear, will be a difficultandtimeconsumingoperation.Itmaytake several days before the accident site can be cleared. During this period, the site should be cordoned off and secured, even if it is all contained within the airport boundary. This is necessary to prevent airside pass holders unwittingly damaging or disturbing either the wreckage or ground marks.

Following an accident at an airport, the AIM will deploy to the scene as quickly as possible and take control of the accident site. When the AAIB team arrive, they will arrange to have the wreckage moved at the earliest opportunity taking advantage of any support the airport can offer in particular, personnel, heavy lifting equipment or storage facilities.

Although the AAIB will dictate the timescale regarding movement of the wreckage, it is the responsibility of the airport authority to decide when it is safe to re-open the runway / taxiway / airport.

18. Accident site security and initial AIM / police actions

It is the responsibility of the police to guard the wreckage and provide security for the accident site. The accident site must beidentifiedandsealedoffassoonaspossible; only people required for rescue and fire-fightingshouldbeallowedaccesstothewreckage.

Where accidents have occurred at night or late in the evening, examination of the wreckage willusuallybepostponeduntilfirstlight.

When wreckage is found, and where in the opinion of the AIM, it is considered to be of significance(instruments,mechanicalpartsetc) the location should be marked and the findshouldbebroughttotheattentionoftheAAIB on their arrival.

Followingtherescueandfirefightingphases,the emergency services are asked to bear in mind that the scene of an aircraft accident may or may not be a crime scene. However, it will always be a scene rich in forensic evidence. Therefore, it is important that the scene is preserved as much as possible until the AAIB Inspectors arrive.

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The AAIB will attempt to keep the period during which the accident site needs to be guarded to a minimum. However, it must be appreciated that the plotting of a wreckage trail andonsiteexaminationscantakeasignificantamount of time, particularly in the case of a large aircraft

Theguardingofasitecanbedifficultgiventhe variability of terrain and the occasional extended areas involved. To ensure that all potential evidence is preserved it is essential that the number of people in and around the wreckage is kept to a minimum. It is all too easy for vital evidence to be destroyed by well intentioned persons disturbing wreckage, obliterating ground marks, trampling equipment into the ground, or moving switches and controls from their original positions.

The media will be well represented and it will probably require some effort to keep photographers, cameramen and journalists at an appropriate distance from the wreckage. However, press photographs taken soon after an accident, albeit from a distance, can provide a useful record of the wreckage distribution or the local weather conditions.

As well as site security the AIM should consider the following initial actions:

Record, as soon as possible, the ●positions in the aircraft wreckage from which any survivors of the accident were assisted

Take photographs, recordings or sketch ●items/evidence considered likely to be obliterated or lost prior to the arrival of the AAIB team

Secure the wreckage, including any ●scattered wreckage away from the main accident site, and any of the aircraft’s contents or papers against loss or further damage

Note the names, addresses, contact ●details and intended movements of any witnesses to the accident

Admit only authorised personnel to the ●accident site; and keep bystanders outside the established zone of safety

Protect, if possible, vital areas such as ●the cockpit, lighter pieces of wreckage and ground scars from inclement weather by covering them with a tarpaulin. (Should coverings not be available, photography and videoing of the scene will assist the investigative team.)

19. Accident site safety

The safety of personnel will be an important consideration for organisations involved in accident site operations.

Someaircraftmaypresentsignificanthazards,for example:

Cargo carrying aircraft ●

Large passenger aircraft carrying ●significantcargo

Lightaircraftfittedwithpyrotechnically ●deployed parachutes

Military or ex-military aircraft equipped ●with ejection seats

The AAIB has access to specialist health and safety advice regarding hazards at aircraft accident sites and the safe recovery of aircraft wreckage. This expertise can be made available to the emergency services at an early stage of response by telephone and/or in person.

Overall responsibility for the safety at the site will usually reside with the authority in control, ie the Fire Service, Police or the AIM. However, organisations working at the site will

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retain responsibility for the safety both for their own personnel and for others working under their direction.

To ensure that a high level of safety management is maintained during site operations, it is important that organisations co-operate and co-ordinate their activities. At major accident sites for example, a risk management group will be formed to assist with the safety management process. Initiation and facilitation of the group is likely to be co-ordinated by the local authority emergency planners (the AAIB may initiate this action if required). Group members should include safety co-ordinators from the main organisations involved, including the AAIB, AIM, Police, Fire, Emergency Planners, Environment Agency, contractors, etc.

Uponcompletionofthefire-fightingandrescuephase, the AIM will assume responsibility for investigation and recovery operations at site until the AAIB team arrives. At this stage, AAIB personnel will undertake further assessment of occupational safety hazards at site. The advice of the senior Fire or PoliceOfficerwillbesoughttoestablishinformationonhazardspreviouslyidentified.Specialistpersonnelsuchasscientificadvisers may also be employed to assist with the assessment process. At major accident sites, this assessment phase is likely to take some time, resulting in a pause in operations before further work can continue. On completion of the assessment, suitable control measures will be introduced to ensure the safety of personnel working at or visiting the site. Control measures are likely to include limitingaccesstoallorspecificsiteareas,theremoval or neutralising of some hazards, the useofprotectiveclothing,restrictionoftrafficmovement, and may also include the operation of an entry pass system.

Some incidents may have implications for public safety and, given the extent and

duration of site operations in major accidents, mayalsohaveasignificantimpactonthedaily routine of the local population. Past experience has shown that the involvement of the Local Authority, and in particular the Emergency Planning department, is essential for the effective co-ordination of non-investigation activities at and around major accident sites. The AAIB will seek to maintain a close liaison with the Local Authority to provide advice and assistance where required.

See Appendix F for more details regarding safety hazards on accident site.

The AAIB has provided personal protective equipment detailed in Appendix I

20. Organisation of the investigation

With the increasing complexity of the aviation environment,eg.flightoperations,aircraftsystems,andairtrafficcontrol,ithasbecomenecessary for the AAIB to call on outside specialists to assist In particular aspects of specificinvestigations.Thesepersonnelcanbe co-opted from:

The airline operator involved ●

The manufacturers of the aircraft, its ●engines or equipment

Other government agencies ●

They will be formed into groups working under the direction of AAIB Inspectors. The number and scope of the groups depends on the site andcomplexityofthespecificaccident.

An Investigator-in-Charge (IiC) will be appointed by the Chief Inspector of Air Accidents and will be responsible to him for the overall organisation, conduct, and control of an accident investigation. The AIM and local team will continue to participate in the investigation as advisors to the IiC.

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The Investigator-in-Charge will decide which specialist working groups are required and will co-ordinate and direct the efforts of the groups. The Investigator-in-Charge will also ensure that regular liaison is maintained between the AAIB, the police incident commander and the Coroner or Procurator Fiscal.

AAIB / Police liaison

The AAIB investigation team will usually have a daily meeting at the end of the day’s activity. Chaired by the IiC, the meeting will discuss progress to date and formulate activity plans for the following day. It is important that the Police nominate a liaison officer to attend these meetings.

Likewise, subject to manpower availability, the AAIB will appoint an inspector to liaise at any dailypolicebriefings.

21. Preservation of evidence

Modern aircraft systems are complex and vital evidence can be destroyed through inadvertent action by members of the emergency services. Therefore, the following guidelines are offered:

Removal of evidence

Apart from casualties, nothing should be removed from the scene nor should the wreckage or accident site be disturbed any more than is necessary for the extrication of persons, making the scene safe for investigators or for preserving evidence. Removal of obviously deceased persons entangled in the wreckage should not be commencedwithoutfirstdiscussingtheissues with the AAIB Duty Co-ordinator. Where such activities have to take place before AAIB Inspectors arrive, a record, preferably a photographic or video record, should be made of the disruption to the wreckage.

Coverage should include an overall view of the site and close-up of the wreckage, especially the cockpit area, and of the bodies.

Runway debris

In the case of accidents and serious incidents occurring at airports there may be debris scattered along the runways or taxiways. There is often considerable pressure to sweep the paved areas to allow operations to continue and the AAIB has no wish to cause unnecessary delays. In such circumstances the AAIB guidance is that, after obtaining the AAIB Duty Co-ordinator’s agreement, the distribution of debris should be recorded, preferably by photography and video. Debris should then be moved to the edge of the paved area in a direction at right angles to the centreline. This will help investigators to reconstruct the failure sequence.

Eye-witnesses

The AIM can assist the AAIB by compiling a list of witnesses, their addresses and telephone numbers and taking their initial statements. It is important that statements bestrictlyconfinedtoarecordofthefactsas seen by the witnesses. Although the police may need these statements for their own purposes, it is important that they be made available to the AAIB. In cases where itisnecessarytotryandestablishthefinalflightpathofanaircraft,thenumberofwitnesses and the area covered by them can be more important than the individual quality of their evidence. Specialist aviation knowledge on the part of a witness is no guarantee of accuracy. It is not unusual for witnesses to have photographs or video recordings of an accident, particularly at air displays. Copies of these (preferably the originals) should be requested from witnesses - they will be analysed by the AAIB and then returned to the owners.

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Passenger questionnaire

Appendix D contains a Passenger Questionnaire which may be copied for local use. (This is also available on the AAIB Website.)

Passengers should be asked to complete this questionnaire, ideally with the assistance of apoliceofficeroramemberofthesupportagencies, who should then ensure that it is given to an AAIB Inspector on site or returned to the AAIB at the address given on the form.

Documents

A large number of documents and papers may be carried by aircraft; the recovery and preservation of these documents may be vital. It is particularly important that the AIM organises this process whilst awaiting arrival of the AAIB team.

All papers associated with an aircraft accident should be carefully collected and held, with a minimum of handling of damaged or burnt specimens.

If the flight deck of a public transport aircraft is intact, access should be prevented and documents not removed unless there is a risk of their loss or damage.

The documents carried often include:

CertificateofAirworthiness –

CertificateofRegistration –

CertificateofMaintenance –

Technical Log –

Load and Balance Sheets –

Passenger Manifest –

Freight Manifests –

Crew Licences –

Crew Log Books –

Navigation Log Sheets –

Aircraft and Operations Manuals –

Maps, Charts and notes etc –

Examination of such documents and analysis of the information contained in them may provide vital evidence for investigators.

Personal technology

Flight crew may carry company-issued laptop computers and mobile telephones as well as their own personal mobile telephones, cameras or PDAs. Even if they appear damaged and unusable they can contain data recorded on microchips..Damaged items should be collected and bagged complete with their damaged components and handed to AAIB personnel.

Flight recorders

Flight Data Recorders (FDR) and Cockpit Voice Recorders (CVR), commonly referred to as ‘Black Boxes’, are carried by many commercial aircraft and can provide vital information to the investigation. These recorders are painted bright orange with white reflectivestripsonthesidesandcontaincrash-protected tape or memory modules where the data is stored.

Unskilledhandlingoftheflightrecordersaftera crash can cause unnecessary damage which might lead to loss of the recorded information, or at the very least, a delay in the recovery of that information.

The retrieval of the recorders after an accident is of prime importance, but electromagnetic devices of the ‘mine-detector’ type should not be used to search for these recorders because the electromagnetism can erase the recorded information.

Onceaflightrecorderhasbeenlocated,it is imperative that its location should be marked and protected; however, if it needs

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to be moved, it should be handled as little as possible before retrieval by AAIB specialists.

The outer casing of older type recorders can be damaged or even destroyed in an accident, leaving only the crash-protected tape module containing the recorded data. If this module issubjectedtofireorimmersioninfluiditcanbecomediscolouredanddifficulttoidentify.

Othersourcesofrecordedflightdataarebecoming more common on commercial aircraft. Of particular use to investigations are Ground Proximity Warning System units (GPWS) and Quick Access Recorders (QAR). These, together with many avionics boxes and engine control units, can store data into memory; however, the memory is not required to be crash protected. Therefore, as a precaution, any electronic boxes found should be protected from further damage until they can be examined or retrieved by AAIB specialists.

GPS units

GPS units are being used more and more by pilotsflyingsmalleraircraftsuchasbusinessjets, GA aircraft and gliders. Some GPS units are panel mounted while portable/handheld units are often positioned somewhere in the cockpitbythepilotatthestartofeachflight.Many of these units are able to store and record track and other information in memory so should be collected and put into antistatic bags, and handed to AAIB personnel. If an antenna is still connected to the unit then this should be disconnected to prevent possible further recording of track information.

Some typical GPS units

Examplesoftypicalflightrecorders - the upper example shows a modern

solid-state recorder with the crash-protected memory module clearly visible with

awhitereflectivelabel

An example of a partially damaged CVR and the discoloured crash-protected tape module

from a damaged FDR

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22. The exchange of witness statements

Oneissuewhichmaycreatedifficulties,particularlyforpoliceofficersandAAIBInspectors when conducting parallel investigations, is the exchange of witness statements.

Normally,thepolicehavenodifficultyingivingcopies of witness statements taken by their officerstoAAIBInspectors.However,theCivil Aviation (Investigation of Air Accidents and Incidents) Regulations prohibits an AAIB Inspector from reciprocating.

The regulation stipulates that no relevant record shall be made available to any person for purposes other than accident or incident investigation unless its disclosure has been ordered by the relevant Court.

Thedefinitionofarelevant record is definedwithinInternationalStandardsandRecommended Practices for Aircraft Accident and Incident Investigation (Annex 13 to the Convention on International Civil Aviation).

Thedefinitionincludes‘allstatementstakenfrom persons by the investigation authorities in the course of their investigation’.

In this context, the investigation authority is the AAIB and not the police.

Consequently, Inspectors of Air Accidents may take formal statements from witnesses but they must not part with copies of such statements to third parties – even if the witness has no objection to a copy being giventothepoliceorCoroner’sofficer. In practice however, AAIB Inspectors prepare three copies of a handwritten statement. One is retained by the Inspector and two are given to the witness so that one may be given to the judicial investigation, if sought, so that bothinvestigationscanbenefitfromthesamewitness evidence.

No offence is committed by the witness if he or she hands a copy of their statement to a third party. However, if a witness declines to part with a copy of their statement, they should not be compelled to do so. Instead, a policeofficershouldtakeanotherstatement.

23. Communications

Although AAIB staff regularly use mobile telephones for on-site communications, on occasions, network coverage is either limited or not available. In these cases it is desirable for the police to assist with communications by providing police radios or alternate telephone links. The AIMshould,ifpossible,confirmlinesofcommunications from the accident site to AAIB HQ not only to ensure that the AAIB Duty Co-ordinator can provide assistance to the AIM or members of his team while the AAIB team is in transit, but also to enable the transmission of digital photographs and/or video taken by crash site managers or witnesses.

24. Pathology - aviation specialists

In the United Kingdom the AAIB team may include a medical adviser. This person is usually, but not exclusively, a specialist in aviation pathology seconded from the RAF. It is important for the pathologist, dealing with an air accident, to have a knowledge of aviation and aviation medicine. Regardless of who conducts post-mortem examinations, it is useful for the aviation pathologist to comment on the examinations to obtain information on:

Evidence of cause of the accident –

Mechanical failure in the aircraft (from –body injury evidence)

Physical evidence of who was controlling –the aircraft? Was there disease which

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couldinfluencethefunctionofthecrewor incapacitate them?

Toxicological. Were the crew affected by –noxious fumes, drugs, or alcohol?

Physiological – . Was there a defect in the pressurisation system?

Evidence of injury by pre-impact –explosionorfire

Evidence of the sequence of events –leading up to the accident

Was the accident anticipated or not? –

Evidence as to survivability –

The aviation pathologist is normally willing to act on behalf of the Coroner if they so desire.

25. Wreckage recovery

Recovery of the wreckage will normally be co-ordinated by the AAIB, with assistance from the AIM.

In all accidents, the prevention of pollution or further damage to land, water course, buildings,etcwillbeasignificantconsiderationfrom an early stage. The AAIB will advise and assist the Emergency Services, Environment Agency, utility companies, etc in gaining access to the site to limit any environmental effects.

At most accident sites, representatives of the aircraft operator/insurers will also attend site at an early stage to assess liabilities and plan restoration/remediation activities. Where complex or extensive restoration work is required, agents will be appointed by the insurers to manage the project.

26. Aircraft accidents at sea

The AAIB is also responsible for the investigation of aircraft accidents where the aircraft crashes into the sea.

Survivors

Survivors from an aircraft that has crashed at sea may be recovered to different shore-based locations and transported to different hospitals or reception centres. It is essential that the police deploy personnel to each location to gather personal information and take witness statements if possible. These statements, especially those from surviving crew members, may be vital in determining the course of events immediately prior to the accident. A detailed list of the survivors names and addresses should be passed to the AIM / AAIB as soon as possible. Those survivors capable of recording their experiences should be given an AAIB passengers questionnaire (see Appendix D).

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Deceased

Bodies recovered from the sea will be recovered to a shore-based mortuary for pathological examination. Where possible a pathologist, specialising in aviation matters, shouldbepresenttoreporthisfindingstotheAAIB team.

Floating debris

Floating debris recovered and brought ashore during the search and rescue phase of any operation should be secured and brought to the attention of the AIM.

Wreckage recovery from the sea

The AAIB will seek to recover aircraft wreckage fromthewater(eitherfloatingorsubmerged)only if it is deemed necessary for the investigation in order to establish the cause of an accident and it is practical to do so.

The recovery of aircraft wreckage from the sea bed can be a very expensive operation with costs varying depending on the size of the aircraft, the depth of water, the location, the weather and sea conditions etc. In some cases the AAIB will make contact with the police, the aircraft operator’s insurers and the State of Registry with a view to seeking an agreement for sharing the costs of the recovery.

In some cases the AAIB may seek to recover onlytheflightdatarecordersandrelevantparts of the aircraft wreckage. This may occur when recovery of all of the aircraft wreckage is impractical. On occasions, when General Aviation aircraft are involved, the AAIB will not attempt wreckage recovery. It will then be the responsibility of the aircraft owner or the aircraft’s insurers to effect a recovery if it is deemed appropriate for their purposes or if the wreckage poses a hazard to shipping.

The AAIB will ascertain, at the earliest opportunity, whether any relevant wreckage is located under water. If this is the case, and

the police are involved, they will be informed of the AAIB process and procedures to prevent the inappropriate use of local resources that may expose AAIB inspectors, arriving on scene, to an environment that has not been subjected to the required risk assessment.

Once it has been ascertained that aircraft wreckage needs to be recovered from water, the AAIB Duty Co-ordinator will use the services of the Salvage & Marine Operations Integrated Project Team (S&MO IPT) and as such, members of S&MO IPT will be authorised as ‘Advisors’ to the AAIB Investigator-in-Charge and considered part of the AAIB team. S&MO is part of the MOD, staffed by MOD civilians and deployable within 24 hours in times of peace orconflicttoanylocationintheworld.Itauthorises and project manages salvage, specialist mooring, blue-water towing and heavy lift transportation services. The Duty Co-ordinator and the AIM will liaise with S&MO to determine the process for recovering the wreckage.

The AAIB will make it clear to the operator of an aircraft which has crashed and sunk that the AAIB will be undertaking the salvage and will be responsible for it. The operator shouldbefirmlydiscouragedfromtakingunilateral action, though he (together with the manufacturer) may send an observer on board the recovery vessel if there is space and accommodation.

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If the aircraft has remained afloat, the operator may wish to salvage his property with a view to refurbishment, in which case the AAIB will render every assistance. If the aircraft subsequently sinks then the AAIB will undertake responsibility for the salvage as before.

Recovery of aircraft recorders

Most public transport aircraft and helicopters are equipped with some form of cockpit voice andflightdatarecorderdesignedtowithstandthe forces involved in an aircraft accident including immersion in water under extreme pressure. These recorders can provide vital information essential to AAIB investigations. Theyarefittedwithtransmitters(DukaneBeacons) to assist with their location under water. The AAIB have the necessary equipment (a handheld receiver and a towed hydrophone array) to detect and locate these transmissions. Some AAIB Inspectors are skilled in the operation of this equipment and will deploy on the recovery vessel to assist in the recovery operation.

The recovery of bodies from within aircraft wreckage

If bodies are discovered in or near submerged aircraft wreckage they will be recovered and dealt with appropriately. It will often be desirable for a police presence on board the recovery vessel to deal with bodies and co-ordinate their eventual transportation to a mortuary ashore.

27. Dealing with the media

It is likely that the media will arrive at scene very shortly after the accident has occurred. If the media arrive before the AIM, for their own safety, they must remain outside the secured area.

The media will have deadlines to meet and willseektogainofficialinformationandtakephotographs of the accident site and survivors as soon as possible. News media aircraft or helicoptersshouldbepreventedfromflyingover or hovering near the accident site and photography of survivors or deceased persons should not be permitted.

The AIM will endeavour, with police assistance, to provide access for the media to an area where suitable photographs may be taken and, at a suitable time, provide a shortfactualbriefing.Membersofthepoliceand emergency services, if called upon by the media, should be aware of the need to refrain from releasing information that is outside their area of expertise. For this reason care should be exercised in the use of mobile telephones or radios, as the media may be capable of monitoring communication frequencies.

The AAIB will not release to the public or media the names of the crew, passengers, the aircraft owner or the operator. The Coroner releases the names of the deceased persons only after the next-of-kin have been informed and will often use the Police as his agents. Speculation as to the cause of the accident must be avoided at all times.



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Appendix APowers of an Inspector

Extract from The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996.

Note: Although these extracts are from the UK regulations, the individual Overseas Territory Regulations are all similar.

Powers of Inspectors

9.—(1) For the purpose of enabling him to carry out an investigation into an accident or incident in the mostefficientwayandwithintheshortesttime,aninvestigatingInspectorisherebyauthorised,whereappropriate in co-operation with the authorities responsible for the judicial inquiry, to—

(a) have free access to the site of the accident or incident as well as to the aircraft, its contents or its wreckage;

(b) ensure an immediate listing of evidence and controlled removal of debris, or components for examination or analysis purposes;

(c) haveimmediateaccesstoanduseofthecontentsoftheflightrecordersandanyotherrecordings;

(d) have access to the results of examination of the bodies of victims or of tests made on samples taken from the bodies of victims;

(e) have immediate access to the results of examinations of the people involved in the operation of the aircraft or of tests made on samples taken from such people;

(f) examine witnesses; and(g) have free access to any relevant information or records held by the owner, the operator or

the manufacturer of the aircraft and by the authorities responsible for civil aviation or airport operation.

(2) For the purpose of paragraph (1) above an investigating Inspector shall have power—

(a) bysummonsunderhishandtocallbeforehimandexamineallsuchpersonsashethinksfit,torequire such persons to answer any question or furnish any information or produce any books, papers, documents and articles which the investigating Inspector may consider relevant and to retain any such books, papers, documents and articles until the completion of the investigation;

(b) totakestatementsfromallsuchpersonsashethinksfitandtorequireanysuchpersontomake and sign a declaration of the truth of the statement made by him;

(c) on production if required of his credentials, to enter and inspect any place, building or aircraft the entry or inspection whereof appears to the investigating Inspector to be requisite for the purposes of the investigation;

(d) on production if required of his credentials, to remove, test, take measures for the preservation of or otherwise deal with any aircraft other than an aircraft involved in the accident or incident where it appears to the investigating Inspector requisite for the purposes of the investigation, and

(e) to take such measures for the preservation of evidence as he considers appropriate.

(3) Every person summoned by an investigating Inspector under paragraph (2)(a) above shall be allowed such expenses as the Secretary of State may determine.




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Appendix A (Cont)Powers of an Inspector

(4) When requested to do so by the investigating body or entity of another member State, the Chief Inspector may provide assistance to that body or entity by supplying—

(a) installations, facilities and equipment for— — the technical investigation of wreckage and aircraft equipment and other objects

relevant to the investigation,—theevaluationofinformationfromflightrecorders,and — the computer storage and evaluation of air accident data, and

(b)accidentinvestigationexpertstoundertakespecifictasksbutonlywhenaninvestigationisopened following a major accident.

(5) In this regulation “operator” shall have the meaning given by Article 3 of the Directive and “in co-operation with the authorities responsible for the judicial inquiry” shall have the same meaning as in the Directive.



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Extract from the Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996.

Note:ThesedefinitionsareidenticalinallOverseasTerritoriesandreflectthedefinitionin ICAO Annex 13.

Accident

2.—(1) In these Regulations, unless the context otherwise requires—

“accident” means an occurrence associated with the operation of an aircraft which takes place betweenthetimeanypersonboardstheaircraftwiththeintentionofflightuntilsuchtimeasallsuch persons have disembarked, in which—

“(a) a person suffers a fatal or serious injury as a result of—

— being in or upon the aircraft,— direct contact with any part of the aircraft, including parts which have become detached from the

aircraft, or— direct exposure to jet blast, exceptwhentheinjuriesarefromnaturalcauses,self-inflictedorinflictedbyotherpersons,

or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew, or

(b) the aircraft sustains damage or structural failure which— —adverselyaffectsthestructuralstrength,performanceorflightcharacteristicsoftheaircraft,and— would normally require major repair or replacement of the affected component, except for engine failure or damage, when the damage is limited to the engine, its cowlings or

accessories; or for damage limited to propellers, wing tips, antennas, tyres, brakes, fairings, small dents or puncture holes in the aircraft skin; or

(c) the aircraft is missing or is completely inaccessible;”

Fatal injury

Fatal injury means an injury which is sustained by a person in an accident and which results in his death within 30 days of the date of the accident;

Serious Injury

Serious injury means an injury which is sustained by a person in an accident and which—

(a) requires hospitalisation for more than 48 hours, commencing within seven days from the date the injury was received;

(b) resultsinafractureofanybone(exceptsimplefracturesoffingers,toes,ornose);(c) involves lacerations which cause severe haemorrhage, nerve, muscle or tendon damage;(d) involves injury to any internal organ;

Appendix B Definitions of an Accident and Serious Incident




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Serious Incident

Serious incident means an incident involving circumstances indicating that an accident nearly occurred;

List of examples of serious incidents - The list is not exhaustive and only serves as a guide to the definitionof‘seriousincident’.

- A near collision requiring an avoidance manoeuvre or when an avoiding manoeuvre would have been appropriate to avoid a collision or an unsafe situation.

- Controlledflightintoterrain(CFIT)onlymarginallyavoided.

- An aborted take-off on a closed or engaged runway, or a take-off from such runway with marginal separation from obstacle(s).

- A landing or attempted landing on a closed or engaged runway.

- Gross failure to achieve predicted performance during take-off or initial climb.

- Allfiresandsmokeinthepassengercompartmentorincargocompartments,orenginefires,eventhoughsuchfiresareextinguishedwithextinguishingagents.

- Anyeventswhichrequiredtheemergencyuseofoxygenbytheflightcrew.

- Aircraftstructuralfailureorenginedisintegrationwhichisnotclassifiedasanaccident.

- Multiple malfunctions of one or more aircraft systems that seriously affect the operation of the aircraft.

- Anycaseofflightcrewincapacitationinflight.

- Any fuel state which would require the declaration of an emergency by the pilot.

- Take-off or landing incidents, such as undershooting, overrunning or running off the side of runways.

- Systemfailures,weatherphenomena,operationoutsidetheapprovedflightenvelopeorotheroccurrenceswhichcouldhavecauseddifficultiescontrollingtheaircraft.

- Failureofmorethanonesysteminaredundancysystemwhichismandatoryforflightguidanceand navigation.

Appendix B (Cont)Definitions of an Accident and Serious Incident

(e) involves second or third degree burns, or any burns affecting more than 5 per cent of the body surface; or

(f) involvesverifiedexposuretoinfectioussubstancesorharmfulradiation;and“seriouslyinjured”shall be construed accordingly;



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To: AIR ACCIDENTS INVESTIGATION BRANCH - 01252 376999

From ............................................................ ORGANISATION .....................................................................Tel .............................................FAXNo .....................................Date. ........................Time .......................

A ACCIDENT INCIDENT REF No ...........................................................................................B AIRCRAFT TYPE and REGISTRATION ..........................................................................................C OWNER ................................................................................................................................................ Tel .................................................. OPERATOR ......................................................................................................................................... Tel ..................................................D PILOT IN COMMAND Name .................................................................................. Address .............................................................................. ........................................................................................... ........................................................................................... ........................................................................................... Tel ..................................................E DATE & TIME (UTC) OF EVENT ..........................................................................................F LAST POINT OF DEPARTURE ........................................................................................... POINT OF INTENDED LANDING ...........................................................................................

G ACCIDENT LOCATION ........................................................................................... ........................................................................................... OS Map No..................Grid Ref .........................................

H PERSONS ON BOARD CREW .........................PASSENGERS .............................

INJURIES CREW PASSENGERS OTHERSFATALSERIOUSMINOR/NONE

I NATURE OF THE EVENT .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. DESCRIPTION OF THE ACCIDENT SITE .............................................................................................................................................................. ..............................................................................................................................................................

PLEASE DO NOT DELAY NOTIFICATION IF SOME OFTHE ABOVE INFORMATION IS NOT AVAILABLE

Appendix CAccident Notification Fax




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Appendix DPassenger Questionnaire

The Air Accidents Investigation Branch (AAIB), part of the Department for Transport (DfT), is responsible for investigatingseriousaircraftaccidentsandincidents.Theaimistomakeflyingsaferbythoroughinvestigationwhichincludes gathering information from both the passengers and crew involved. It would therefore be appreciated if you would assist the investigation by completing as much of the following questionnaire as possible. Thank you.

Personal Details

Full name: ......................................................................................................................................................................

Address: ......................................................................................................................................................................

......................................................................................................................................................................

......................................................................................................................................................................

Telephone: (Home) .......................................(Work) ............................................(Mobile) ...............................................

Occupation: ..............................................................email: ...........................................................................................

Age: .......................... Gender: Male / Female (Please delete as appropriate)

Flight Details

Date: ....................................................................... Flight No: ................................................................................

Airline: ....................................................................... Aircraft type: .............................................................................

From: ....................................................................... To: ................................................................................

Seat Position

Sitting in row number: .................... seat letter: ........................ or I do not remember my seat number

Was this the seat given on your boarding card? Yes / No

Class Area of Cabin Seat Side

First / Business / Economy Front / Centre / Rear Aisle / Centre / Window Left / Right / Centre

Names of other persons travelling with you:....................................................................................................................

Was there a seat on your left: Yes / No Occupied: Yes / No By a: Male / Female Approx age: ...............

Was there a seat on your right: Yes / No Occupied Yes / No By a: Male / Female Approx age: ...............

Description of Event

How and when did you realise something was wrong? ...................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

Please give a brief account of what you heard and/or saw: ............................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................Page 1 Continued overleaf

PassengerQuestionnaire AAIB

Air Accidents Investigation Branch



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Appendix D (Cont)Passenger Questionnaire

Leaving the Aircraft

Did you hear any announcements made by the crew of the aircraft? Yes / No

Were they clear? Yes / No Where you able to follow the instructions? Yes / No

Were any the the following illuminated? Cabin lights / Seat belt signs / Emergency exit lights / Floor level lighting

Please indicate how you left the aircraft:

I left the aircraft by a: Door / Over-wing exit / Break in cabin wall using: Steps / Escape slide / Other

on the : Left / Right at the: Front / Centre / Rear of the aircraft

Please describeanydifficultiesencountered:(egexitimpeded,overheadbinsfallingopen) .......................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

Injuries:

Pleasebrieflydescribeanyinjuriesyousufferedandhowtheyoccurred: ......................................................................

.........................................................................................................................................................................................

Fire:

Pleasedecribeanyfire or smoke: ...................................................................................................................................

.........................................................................................................................................................................................

General comments:

Is there anything else you feel would help our investigation? (eg did you take cabin baggage with you) .....................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

.........................................................................................................................................................................................

Thankyouforhelpingwithourinvestigation.PleasegivethisquestionnairetoanAAIBinspector,apoliceofficer,orreturn it by post or email to the following address:

ISU, Air Accidents Investigation Branch, Farnborough House, Berkshire Copse Road; Aldershot, Hampshire, GU11 2HHUnited Kingdomemail: [email protected]

If you have any questions, or any points you wish to discuss please write to us at the above address or contact us by telephone on +44 (0) 1252 510300 or by fax on +44 (0) 1252 376999. More information on the AAIB is available on our web site at www.aaib.gov.uk, including a printable version of this form.

A report concerning this investigation will be published when the investigation is complete and will be available on our website.

Page 2 Thank you October 2008


PassengerQuestionnaire

L R




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Appendix E Aircraft Accident Investigation - Managing the first 48 hours

(Checklist for Overseas Territories)

The following checklist has been formulated to assist the locally appointed Accident Investigation Manager (AIM) and his/her team in dealing with the immediate aftermath following an aircraft accident.

Overview

Decisions ●Notification ●Accident site Security ●Preservation of physical evidence ●Survivors and fatally injured ●Preservation of recorded data ●Recording of the site / wreckage ●Pressandmediabriefings ●Accident site hazards ●Recovery, transportation and storage of wreckage ●Working facilities ●Initial information ●AAIBteambriefing ●

1 Decisions

Is it a reportable accident or serious incident? - contact AAIB ●What level of investigation is required? ●Who is the nominate Accident Investigation Manager (AIM) - appointed by the Governor’s ●OfficeRefer to the MoU - contact the AAIB who will appoint an IiC ●Do you need resources additional to AAIB – can AAIB assist with these? ●Is the accident interfering with transport links – ie runway blocked? ●Transport arrangements If airport not functional? ●Funding for major recovery operations – sea salvage (circa £100,000 / day)? ●

2 Notification

ACCIDnotificationtotheAAIBinaccordancewithICAOAnnex13 ●AAIB will then notify: ●

State of Operator ●State of Manufacture / Design ●State of Registry ●State with special interest ●

ContacttheAAIB+441252512299(AAIBbyDayandDfTDutyOfficeratNight) ●E-mail: [email protected] ●



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3 Security

Security of accident site & aircraft wreckage ●On airport – Control already established ●Off airport – Police, local resources ●At sea – coastguard, navy, local resources ●Arrange for 24 hour guarding if practicable - control and restrict site access ●Assess if wreckage is complete at site – if necessary, arrange further searches ●

4 Preservation of physical evidence

Disturbance to the accident site and wreckage must be kept to a minimum ●Secure ‘perishable’ evidence ●Fuel / Oil / Hydraulic samples (in sterile containers) ●Papers/maps/charts/flightdocuments/crewpersonalitems ●Arrange for photographs / video ●Cockpit switch / control positions ●Control surface / trim tab positions ●Ground impact marks / runway marks ●Aerial photography of accident site ●Secure other related documentation ●Maintenancerecords/aircraftlogbooks/airworthinesscertificates ●Flight crew licences / training records / log books ●

5 Survivors and fatally injured

Crew list & passenger / cargo manifests ●Next of kin details, if applicable ●Familyliaison(assumefivefamilymembersperpassenger) ●Body recovery / storage – corner’s procedures ●Who has responsibility? ●Is an aero-medical pathologist available? ●Ensure the locations of bodies or human remains are established (photo / diagram) before ●removal, where possibleIs protective equipment available? ●Are decontamination procedures in place? ●Arerefrigeratedstoragefacilitiesidentified? ●

Appendix E (Cont)Aircraft Accident Investigation - Managing the first 48 hours





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6 Preservation of recorded data

Locate data / voice recorders and recover if practicable - seek advice for handling and storage ●fromAAIBorqualifiedorganisationUnderwater transmitter (circa 28 days battery life) ●Preserve other recorders such as GPS units ●Establish if radio / radar data is recorded – ensure such data is located and secured ●Establish if other sources (eg security cameras) may hold evidence ●

7 Recording of accident site and wreckage

Arrange for overall photographic coverage (and video, if available) of site / wreckage ●Make a basic wreckage plot / diagram - ● essential if wreckage is to be moved (eg to clear a runway for use). Use GPS to assist, if availableAttempt to procure detailed maps of accident area ●

8 Recovery, transportation and storage of wreckage

Assess the likely requirements ●Equipment / manpower ●What resources can be made available ●Identify possible storage locations (preferably not connected with an interested party) ●Anticipate likely problem areas ●Is specialist equipment required? ●Underwater salvage (Furgo, CSALMO, etc) ●Shore-side reception area for wreckage ●Contact the AAIB if necessary ●

9 Working facilities

OfficeHQforAAIBandlocalinvestigationstaff, ● ideally with:Telephone / fax / power / internet ●basic stationery items / refreshment facilities ●Secure storage area ●Where necessary and possible, arrange for clearance in advance for access to secure areas ●(eg airport aprons / installations)Domestic arrangements ●Assistance with booking local accommodation for AAIB personnel. ●Hire car(s) for investigation team. ●Travel arrangements to and from accident site ●





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10 Press and media briefings

Be prepared for public journalism ●Mobile phone / digital pictures /video ●Nominate a press liaison person ●Nominateanappropriatespokesperson(‘facetocamera’)-liaisewithotheragencies-agreebriefing ●Establishalocationandfacilitiesforpressbriefings ●Prepare a ‘holding’ announcement ●Consult AAIB for guidance if required ●

11 Accident site hazards

Establish if ‘dangerous goods’ are involved ●Attempt to establish extent of: ●

Hygienehazards(humanremains,bodyfluids) ●Chemicalhazard(egfuel,hydraulicfluids) ●Pressure vessels (eg accumulators, extinguishers) ●Pyrotechnic hazards (eg munitions, survival aids) ●Other hazards – fumes / dust / vapours / radioactive components ●

Contact AAIB H&S advisor / Duty Co-ordinator ●

12 Initial information

Witnesses

List of eye-witnesses (often obtained from Police) ●Conduct initial interviews with key witnesses, if possible ●Request copies of Police witness statements ●

Operational information

Weather information ●Search and rescue procedures ●Accident / disaster plans that were put into action ●Airport / navigational information (including relevant charts / documents) ●Aircraftflightmanuals ●Local procedures / regulations ●Aeronautical Information Publications ●

13 AAIB team briefing

Plan to brief the AAIB team on their arrival ●This should be in a private location, and restricted to those personnel directly involved in the ●investigation / rescue / recovery processThebriefingshouldcovertheknownfactsandwhatactionshavebeentakentodate ●






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Appendix F Accident Site Hazards

Introduction

Aircraft accidents have the potential to expose responding personnel to a wide range of health and safety hazards. These hazards, generated by damage to aircraft structures, systems, components andaircraftcontents,willbehighlyvariableinnatureandwillbeinfluencedbyfactorsassociatedwith the accident scenario, eg aircraft size and type, degree of damage, accident location, weather conditions, environment, security, etc. It is important therefore that responding personnel are aware of the hazards likely to be present at accident sites, and take the appropriate measures to assist in reducing the risks from exposure to such hazards.

The following, non-exhaustive, list provides details on generic hazards associated with aircraft accidents.Furtherinformationonhazardsandassistancewithdeterminingriskinspecificaccidents,particularly during the early stages of response, can be sought by contacting the AAIB.

Flammable substances

Fuel is the primary hazard in almost all aircraft accidents:

Aviation gasoline (AVGAS) is used in piston engine aircraft

Motor gasoline (MOGAS) is road vehicle petrol used in some aircraft engines

Aviation turbine fuel (AVTUR) (kerosene) is used in jet or turbo-prop aircraft

Diesel is also used, although currently not widely

Fuelshavedifferentcharacteristicswithvaryingflashpoints.However,allfueltypespresenthazardsduetotheirflammabilityandconstituteasignificantriskinaccidentsituations.Fuelscanalsopresent hazards through the inhalation of vapour and due to skin contact. Therefore, effective control measures should be established to reduce the risk of exposure through all these routes. Generally speaking, the larger the aircraft, the higher volume of fuel that can be carried.

Damaged structures

Accident damaged aircraft present a variety of hazards: sharp and jagged edges, unstable or weak structures, and retained energy (pressurised, or spring / cartridge assisted components).

Pressurised systems and containers

Avarietyofcontainersmaybeusedtoholdpressurisedgasesandfluids:hydraulicfluids,nitrogen,oxygen,air,fireextinguishinggases/fluids/powders,etc.Pressurescanbeuptoseveralthousandpsi / several hundred Bar. Sudden release of these substances can pose hazards in terms of impact, absorption,inhalationandfire.



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Appendix F (Cont)Accident Site Hazards

Cargo

CargocanvaryinvolumeandvarietyandwillbeidentifiedasDangerousGoodsornon-hazardous.However,irrespectiveofclassification,allcargosubjectedtotheeffectsoffireandimpactinaircraft accidents can be harmful to responding personnel and to the environment. In cargo aircraft accidents it is important for all agencies to co-ordinate efforts to identify cargo and determine the hazards as early as possible.

(Note:Manylargepassengeraircraftalsocarrysignificantamountsofcargo.)

Blood-borne pathogens

The variety and nature of blood-borne pathogens is likely to be one of the more well researched hazards associated with transport accidents. Aircraft accidents present different challenges due to the potential for a large numbers of casualties. In addition, ‘high-speed impact’ accidents can generatetraumaticdamagetocasualtiesthatpresentssignificantdifficultiesintheidentificationandrecovery of victims. In this situation, response and recovery teams, working with the AAIB, need to establish good systems of work to reduce the potential exposure to blood-borne pathogens.

Aircraft escape systems

Military aircraft and some ex-military aircraft may have ejector seats, explosive canopy release systems,andequipmentjettisonsystems.Allofwhichcanpresentsignificantriskofinjurytoresponding personnel. Extreme care should be exercised when attempting to rescue personnel from these aircraft, and wherever possible, the advice and assistance of trained personnel should be obtained before attempting to do so.

For military aircraft, the nearest MoD establishment will be able to direct suitably trained personnel to the site to make the systems safe

For ex-military aircraft, the AAIB will be able to contact suitably trained personnel to assist response personnel

Weapon systems

Military aircraft should be suspected of carrying some form of military pyrotechnics or weapons untilconfirmedotherwise.ThenearestMoDestablishmentwillquicklybeabletogetconfirmationof the carriage of any weaponry and will be able to direct suitably trained personnel to the accident site to assist.

Cartridge initiated devices

Aircraft may carry a variety of cartridge initiated devices for rapid activation of certain systems. These cartridges produce a small volume of gas to release other gases, or operate mechanical systems.Theseareoftenusedforfireextinguishersystems,escapeslides,winchandunder-slungloadcablecutters,andflotationgear.Theunexpectedoperationofthesecartridgesisunlikelytoposeanysignificanthazard.However,theunexpectedactivationofthedevicestheyoperatecanpresent some hazards through impact or exposure to released gases.



Appendix F (Cont)Accident Site Hazards

44


Pyrotechnics

Pyrotechnicsmaybecarriedbyaircraftintheformofsignalflaresorsmokegenerationdevices.These are likely to be associated with emergency equipment such as life-rafts or dinghys. Some lightaircraftcanalsobefittedwitharocket-activatedballisticrecoveryparachutesystem.

Fire & impact damaged materials

Many of the materials used in aircraft construction can produce harmful gases, vapour and particulates when subjected to the extreme effects of air accidents.

Aluminium - used in aircraft structuresMagnesium - used in components such as wheels and gearboxesOther metals and alloys - used in engines and systemsComposite materials(carbon,glass,andotherfibresinaresinmatrix)-usedinmajorparts

of the structure in more modern aircraft. When burnt or impact damaged these oftenproducefreefibreswhicharehighlyirritant

Control measures for all burnt materials should include limiting exposure, suppression of particulate withwaterorfluids,andwhererequired,theuseofPersonalProtectiveEquipment(PPE).SeeAppendix I.

Electrical systems

Electrical batteries and emergency power supplies present hazards due to their electrical potential, becauseoftheirchemicalcontent,andduetoheatandfirecausedshouldaninternalshortcircuitoccur. Systems should be isolated as early as possible.




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Appendix G UK Overseas Territories Aircraft Accident Response Training Course

Introduction

The training course is designed to provide key personnel, resident in a UK Overseas Territory, with the skillsandknowledgenecessarytomanageanaircraftaccidentinvestigationforthefirst48hourswhilethe AAIB Investigator-in-Charge and his team are en-route to the accident site. It is not designed to train key personnel as accident investigators.

Primarily the role of the nominated Accident Investigation Manager (AIM) is to manage the processes carriedoutbythepolice,emergencyservices,airfieldandATCoperator,aircraftoperatoretctoensurethe preservation and/or recording of perishable evidence and that the appropriate and timely actions are carried out for the removal, collection and preservation of the aircraft wreckage as detailed in the ‘Checklist for Overseas Territories’ (Aircraft Accident Investigation - Managing the First 48 hours).

While the course can provide the AIM and other personnel with guidance information it will highlight processes and procedures where it will be essential for the nominated AIM to maintain regular communications with the AAIB HQ staff until the IiC arrives on site when a handover between the AIM and IiC can be carried out.

Instructors

The course, carried out in the OT concerned, will normally be conducted by an AAIB team consisting of a Principal Inspector, a Senior Inspector (of a different speciality) and a Health & Safety / Engineering Support Manager. In some circumstances the team may be augmented by a senior member of the Administrative Support Staff (IU / ISU) who will be required to present information concerning the establishment of a forward Operating HQ.

Target audience

Course participants should consist of:

The DCA and members of his/her staff ●The Airport Manager and senior members of the airport management staff ●Seniorofficialsinthepoliceforce ●Representative(s)fromtheGovernor’sOffice ●SeniorRescueandFirefightingpersonnel ●TheLocalemergencyplanningofficer ●Members of the Department of Disaster Management from the Government (or equivalent) ●Senior Representatives from the emergency medical services ●AnyotherTerritorypersonneldeemedappropriatebytheGovernor’sOffice ●

The formal training contains a number of presentations and exercises and, where possible, an emergency exercise should be conducted immediately following the training so that AAIB personnel can monitor and provide feedback on areas for improvement.




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Appendix G (Cont)UK Overseas Territories Aircraft Accident Response Training Course

Course Aims

1. To explain the purpose of air accident investigation2. To highlight what an air accident involves3. To train key personnel in managing the initial response to an accident until the AAIB

Investigator-in-Charge and his team arrives4. To explain the AAIB’s roles and responsibilities

Course Content will include

DAY 1

Introduction ● (Governor’sOffice/AAIB/Delegates)Purpose of Air Accident Investigation ● (Annex13,TheRegulations,SafetyBenefits)Initial Accident Response ● (Accident reporting / organisation / logistics / media response) Aircraft Accidents Overview ● (Types of accidents, scenario presentations)Workshop 1: ‘Initial Response’ ● (Group Exercise; three scenarios)Health & Safety Risks on Site ● (Including workshop / PPE demo)

DAY 2

Evidence Gathering & Preservation ●The Operations Investigation ● Workshop 2: ‘Initial On-site Actions’ ● (Group Exercise; three scenarios)Wreckage Recovery ● Workshop 3: ● ‘Evidence Gathering and Preservation’ (Group Exercise - three scenarios)Investigation Progression ●Conclusions and Summary ●Course review / Questions / Presentation of Certificates / Feedback forms ●



47


Appendix HAccident Investigation Manager (AIM) Training Course

Introduction

All AIM’s must undertake an AAIB approved training course to enable them to conduct their responsibilitiessafelyandefficiently.Although‘OnTheJob’trainingwouldbeideal,thisisrecognisedas impractical and so any approved course will include a practical accident site simulation.

Training Course Objectives:

1. Capability to deploy a suitable trained team to the accident site:

Developing a suitable contact list and means of deploying those team membersi. Briefingthelocalteampriortoenteringtheaccidentsiteii. Managing the welfare of the investigative teamiii.

2. Accident site health and safety considerations:

i. Awareness of potential accident site hazardsii. Implications of any dangerous cargoiii. Maintaining and disseminating the AAIB provided support equipment

3. Preservation of accident site and evidence until AAIB team arrive:

i. Managing the preservation of physical evidence at the sceneii. Decision making (in discussion with AAIB) on any wreckage removaliii. Managing the witness interviewsiv. Preservingdocumentationatsiteanddepartureairfield/homebasev. Identifying and preserving FDR / CVRvi. Preserving radar / radio / GPS / NVM datavii. Identifying facilities and equipment for eventual wreckage recovery

4. Operating with AAIB:

i. Initialbriefingii. Continued contact utilising photographs/video/conference facilitiesiii. Handover brief to AAIB team on arrivaliv. Continued investigation as advisor to the AAIB team

5. Working with other authorities:

i. Interfacing with Police, Fire, Ambulance, Search and Rescue, Accredited Representatives, Coroner

6. Working with the media:

i. Understanding the use of the mediaii. Giving interviews and preparing press releases




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48

Appendix IOverseas Territories - Health & Safety and Investigation Support Equipment List

The equipment listed below is considered to be the minimum required to provide for investigation/site managementpersonnelrespondingtoaircraftaccidents.AAIBInspectorswillcarrysufficientpersonalprotectiveequipmentfor24hoursusebutthestorageofthis‘on-site’equipmentshouldbesufficienttoprovideadditionalsupportforfiveInspectorsforuptofourdaysinthe‘field’.Thisequipmentshouldbe pre-packed and readily available. The contents should be reviewed annually and replenished when necessary.

Personal Protective Equipment

Responding personnel must have suitable protective footwear and outer clothing for the conditions they are likely to encounter but in addition the following should be available:

Disposable paper masks - 30Halfmaskrespiratorsandfilters-5Disposable paper overalls - 50Hard hats - 5Ear defenders - 5Goggles - 5Heavy duty gloves - 30 pairs

Disposable bio-protective gloves - 200 pairsFirst aid kitHand cleanserPaper wipesDisinfectant Bio cleansing wipesTarpaulins - 5

Investigation Equipment

Distance measure wheelDigital still cameraDigital video cameraGPS Adhesive tapesFunnelHand toolsSafety tabards Coloured marking pvc tapes10 m and 50 m measuring tapesPlastic sample bagsSample bottlesFuel sample cans and labelsMarking tapes and labelsPaint pens

Hand cleanserTissuesTorch & batteriesMagnifying glassVapour proof plastic bagsAnti-static bagsChalkTie-wrapsKnifeCompassBio-hazard sacksSolvent cleanerPaper towelsWreckage sacks (heavy duty plastic bags and

large sacks or containers)



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Appendix JExamples of Overseas Territories Aircraft Accident Reporting Forms (AARF)

General Aviation (GA)




50

Appendix J (Cont)Examples of Overseas Territories Aircraft Accident Reporting Forms (AARF)

General Aviation (GA) (Cont)



51







52





53







54





55







56


Commercial Air Transport (CAT)



57



Commercial Air Transport (CAT) (Cont)




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60





61







62



63




Notes

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Notes

65




Notes

66




Notes


AIRCRAFT ACCIDENT

INVESTIGATIONin

THE UK OVERSEAS TERRITORIES

AIRCRAFT ACCIDENTINVESTIGATION

in

THE UK OVERSEASTERRITORIES

Produced by the Air Accidents Investigation Branchwww.aaib.gov.uk

December 2009

AIR

CR

AFT A

CC

IDEN

T INVESTIG

ATION

in THE U

K O

VERSEA

S TERR

ITOR

IES D

ecember 2009


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